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Nursing progress notes cheat sheet

Rehabilitation   (887 Views 2 Comments)
by ericalin143 ericalin143 (New Member) New Member

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Hello .

I'm trying to find a good cheat sheet for when I write antibiotic infection notes and progress notes on residents/patirnts. I plan on using the acronym SOAP for structure. I would like a little more guidance in verbage and make the best notes possible.

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4 Likes; 492 Visitors; 22 Posts

These are some notes my peers and I tend to write on some brief examples to give you some examples:

ABT therapy: Pt. on ABT tolerating therapy [insert name/dosage/route] with no adverse reactions noted. [temperature and other vitals that you may think is pertinent].

Lung sounds auscultated with findings, skin temperature ( is the patient flushed?) findings.

If on IV: additionally, IV line patent, no s/s of phlebitis and infiltration.

--

Other notes:

( refusal of care)

Pt.  found to self remove  [apparatus] ( such as sling or abductor pillow, very major points of care). Education on [apparatus] ( specifically what you may have explained). Patient states understanding, " jfhsdkfhsjkf" but continues to non-adhere to precautions. Reapproached and stressed importance, patient continues to refuse. [ Other interventions you may have to do to maintain patient safety.] MD called/made aware. Will continue to monitor ( any vitals or pulses that may be pertinent).

 

Documenting IV and refusal of care has saved my butt many times ( not a lot of phonecalls!) and I hope this helped.

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